The MRI scans show a ruptured ACL and possible MCL rupture in the knee of an 18-year-old football player who heard a pop while changing directions. Non-operative management is an option if the patient is willing to modify activities, but given his young age and activity level, ACL reconstruction is recommended, likely using a bone-patellar tendon-bone graft. Post-op rehabilitation would include a knee brace and protected range of motion exercises initially before a gradual return to sports over 9-12 months. The x-rays of a 26-year-old man with longstanding joint pain show diffuse osteopenia, joint space narrowing, and erosions in the hips, knees, and hands.

1. Gashaye T.
Case discussion

2. Q 22
 These are
MRI
scans of
the
injured
knee of
an 18-
year-old
junior
football
player. He
heard
large pop
when he
tried to
change
direction.

3. MRI knee anatomy

4. Questions
 What does the MRI show?
 Sagittal and coronal intercondylar section of knee
MRI
 SIGNAL change over ACL…coronal view
otherwise PCL is not clearly seen .. no comment
 Sagittal view
 Signal change over MCL
 LCL not clear
 PCL…seems normal
Dx : ACL rupture +?MCL rupture

5. How would you treat this injury?
Option
1. Non operative management
 willing to make lifestyle changes and avoid the
activities that cause recurrent instability
 an aggressive rehabilitation program and
counseling about activity level
 Functional knee Brace does not decrease reinjure
risk
2. repair of the anterior cruciate ligament (either
isolated or with augmentation)
3. reconstruction with either autograft or allograft
tissues or synthetics

6. When would you perform
reconstruction?
 He is young active sport man need repair of ACL or
reconstruction
 Either immediate repair or wait for MCL healing at
least two weeks
 Immediate repair
 mid substance tear high failure rate
 Recommended for avulsion injury
 Reconstruction
 Arthroscopic
 miniarthrotomy
 Resolution of inflammation around the knee and
return of full motion reduce the incidence of
postoperative knee stiffness

7. What are the graft choices for ACL
reconstruction?
 Auto graft
 low risk of adverse inflammatory reaction and virtually no
risk of disease transmission.
 Allograft
 bone–patellar tendon–bone graft
 usually is an 8- to 11-mm-wide
 from the central third of the patellar tendon, with its
adjacent patella and tibial bone blocks.
 high ultimate tensile load (approximately 2300 N),
 stiffness (approximately 620 N/mm)
 rigid fixation with its attached bony ends

8. Cont.
 quadrupled hamstring tendon graft
 semitendinosus or gracilis tendon
 ultimate tensile load reported to be as high as 4108 N
 Healing problem
 Lack rigid fixation
 quadriceps tendon graft
 harvested with a portion of patellar bone or entirely as a
soft-tissue graft
 ultimate tensile load of this graft to be as high as 2352 N
 for revision anterior cruciate ligament surgeries and for
knees with multiple ligament injuries

9. What would be your choice and why?
 BBPT
 simple to develop
 Strong fixation
 Low failure rate 3.1% as compared to hamstring
4.1%
 Problem
 Anterior knee pain
 Pain during kneeling
 Frequency of additional surgery seemed to be
related to the fixation method and not the graft
type

10. What are the key steps in performing
an ACL reconstruction?
 Diagnosis
 Graft development
 Graft placement
 Notchplasty
 Tibia and femoral tunneling
 Graft tensioning
 Graft fixation

11.  What fixation would you use?
 Direct fixation devices include interference
screws, staples, washers, and cross pins
 Indirect fixation devices include polyester
tape/titanium button and suture-post.

12. program be, and when would you
allow him to return to playing
football?
 The knee is placed in a controlled motion brace
locked in full extension.
 Protected range-of-motion exercises are begun
immediately
 Return for self training about 4month
 return to team practices with criteria and
limitations from the physical therapist by 6th
month
 Return to contact sport 9 to 12month

13. Q23.
 These are serious of x
rays of a 26 year old
man who presented with
longstanding complaint
of multiple joint pain
predominantly affecting
his neck, hip, knee and
hand areas
symmetrically.
 He is getting shorter
and crippled.

15. Questions
 Describe the x ray findings in each region?
 AP pelvic x ray
 Diffuse Osteopenia
 Deformed head ,flattened with significant joint space
narrowing
 Periarticular erosion
 No protrusion acetabula seen
 Knee x ray
 Joint space narrowing
 Periarticular Osteopnia and some erosion
 No osteophyte seen
 Hand x ray
 Multiple joint involvement both IP joint with osteopnia and
destructed joint
 No gross subluxation or dislocation seen

16. What additional work up do you
order?
 CBC
 Normocytic anemia with
increase plat count
 ESR,CRP
 elevated
 OFT(LFT,RFT)
 Albumin low
 RF
 High sen with low specificity
 ANAs
 Anti-CCPs
 Similar sensitivity with RF
but high specificity 95%
 MRI—bone marrow
edema espcially in early
arthrities
 Show synovities and
erosion
 Ultrasound
 Show erosion
 Synovial fluid analysis

17. Cont.
 What is your diagnosis?
 Rheumatoid Arthritis
 Favor
 Poly articular involvement
 Symmetrical
 X ray finding
 Cervical spine involvement
 Against
 Male sex
 ?DIP joint involved
 Large joint involvement
 What are the possible DDXs?
 RA
 OA
 Lupus arthritis
 Gout & Pseudo-gout
 Psoriatic arthritis
 Reactive arthritis

18. What diagnostic criteria you know
about this pt’s case?
 American college of
Rheumatology criteria, 1987
 The presence of at least 4
out of7 is required to classify
as RA
 Early morning stiffness >1hr
 Arthritis affecting 3 or more
joint areas
 Hand joint arthritis
 Symmetrical arthritis
 Rheumatoid nodules
 Rheumatoid factor
 Bone erosions
symptoms need to be
present for at least 6 wks to
make the Dx
 2010 new criteria
established by American
college of Rheumatology
& Eurpoean League
Against Rheumatism
(ACR/EULAR) score of
>6  unequivocal RA dx

19. What will be the management
algorism to treat this patient?
 It has no cure!
 Goal of treatment
 Symptomatic
improvement
 Slow disease
progression
 Prevent deformity and
treat
 Maintain function

20. Cont.

21. Cont.
 Generally management of RA
 Multidiciplanary
 General/non pharmacology
 Pt education or counseling
 exercise, diet, massage, stress
reduction, physical therapy
 active participation of the patient and
family
 Medical
 nonsteroidal anti-inflammatory drugs
(NSAIDs)
 nonbiologic and biologic disease-
modifying antirheumatic drugs
(DMARDs),
 immunosuppressants, and
corticosteroids
 surgical
Nonbiologic DMARD
Hydroxychloroquine
Azathioprine (AZA)
SSZ
MTX
Leflunomide
Cyclosporine
Gold salts
D-penicillamine
Minocycline
Biologic
DMARDs
adalimumab,
certolizumab,
etanercept,
golimumab and
infliximab.
TNF-α and interleukin (IL)-1 as central
proinflammatory cytokines
biologic agents-block these cytokines or
their effects.

22. Cont.
1st line Low dose steroids
2nd line DMARDs
3rd line DMARDs + biologic
agents/TNF
antagonists
4th line DMARDs +
Biologic agents/ IL-
1 antagonists

23. Cont.

25. Cont.
 SURGERY
 Synovectomy
 Tenosynovectomy
 Tendon realignment
 Reconstructive
surgery or
arthroplasty
 Arthrodesis
 Indications
 Involvement of one or few
joints
 Hyperplastic, “wet”
rheumatoid synovitis
 Failure to respond to
adequate trial of
nonoperative treatment
 No radiographic evidence
of articular cartilage
destruction
 Contraindications
 Seronegative “dry”
synovitis
 Polyarticular involvement
 Acute inflammatory stage
 Systemic disease

26. What is the unique challenge of
doing arthroplasty in such a patient?
 High risk of wear and failure
 High infection rate
 High dislocation rate as compared OA
 WHY?
 Implant choice
 Medical profile
 rehabilitation

27. Q 24
 A 62-year-old lady who
underwent a total hip
replacement four weeks
ago presents to EOPD
following a fall with severe
pain and inability to
weight-bear.
 This is her radiograph

28. Questions
 Describe the
abnormal findings on
the radiograph.
 Right hip AP x ray
 With cemented
femoral stem
dislocated posteriorly
from acetabular cup
 Grossly osteopenia
 What further
information would you
like to obtain on
history?
 Detailed history about
fall down injury
 Why this was done
primarily
 Other injury
 Presence of fever
previous to fall down

29. Cont..
 What further investigations would you request, if
any?
 CDC,ESR,CRP
 What is the diagnosis?
 Posterior dislocation after THA

30. What are the causes for a dislocation
following a total hip replacement?
 Different etiology dislocation
 Trauma
 Laxity
 Repair of the capsule and short external rotator
 Intraoperative assessment of the tension by telescoping of the
femoral stem
 Implant malposition
 safe zone’ of acetabular component 40° of inclination and 15° ±10°anteversion
 Femur stem antetorsion 15° ± 5°
 Both cup and stem position
 Improper implant choice
 Small size head ..jumping distance small high rate of dislocation with low wear
effect
 Large size head …low dislocation risk
 Impingement
 Osteophytes on both the acetabular or femoral side, capsular tissue, or scar tissue
can cause a dislocation displacing the head to posterior or anterior
 Noncompliant to post op rehab
 Neuromuscular disorders with pathologically increased muscle tension such as
Parkinson’s disease, cerebral palsy, and epilepsy

31. What treatment would you offer her?
Why?
 Closed reduction is carried out as soon as
possible after diagnosis to avoid neurologic injury
 Optimally, general anesthesia and fluoroscopy
are required, and commonly, 2 surgeons are
required to safely perform reduction maneuver
 Open reduction
 closed reduction fails or re-dislocation
 dislocation with massive hematoma formation
and/or palsy of the femoral or sciatic nerve occurs,
open reduction is mandatory

32. Surgical treatment option of
dislocation THA

33. Reference
 Campbell's operative orthopedics
 Orthobullet
 Rockwood and Green’s Fractures in Adults 8e
 Musculoskeletal MRI, 2nd Edition Clyde A.
Helms...Saunders (2008)
 A systematic review of guidelines for managing
rheumatoid arthritis
 Rheumatoid arthritis in adults: management NICE
guideline 2018
 Dislocation after total hip arthroplasty A. Zahar &
A. Rastogi & D. Kendoff

34.  Thank you!